LTFs of the distal humerus occur mainly in the elderly osteoporotic population and distal humeral fractures in the elderly population are on the rise.[2, 12, 13] In previous studies, there were many reports that total elbow arthroplasty was superior to ORIF in terms of reoperation rate and complications.[14, 15] However, recently, studies have been reported that the results of bi-columnar fixation using pre-contoured locking plate are similar to or superior to those of total elbow arthroplasty. Goyal et al. reported that patients who underwent the primary procedure between 2006 and 2016, there was no significant difference in reoperation risk between total elbow arthroplasty and ORIF. The reoperations for TEA consisted of 6.3% aseptic revision, 2.1% removal of implant, and 1.4% elbow release, together comprising nearly 90% of the total reoperations. Conversely, approximately half of the ORIF reoperations (12.1%) were removal of instrumentation. This tends to be a more minor reoperation, assuming that the fracture is healed at the time the instrumentation is removed. It is now generally accepted that the most favorable outcomes can be provided by surgical reduction through elbow posterior approach and rigid internal fixation. Since the posterior approach is performed in the lateral or prone position, most surgery require general anesthesia. Therefore, patients whose state of health precludes general anesthesia, may have to choose non-surgical treatments, predicting the outcome for which, is difficult.
Ulnar neuropathy poses a unique challenge to the posterior elbow approach, as it can be a product of surgical management and associated with DHFs in up to 50% of patients. The meta-analysis of Shearin et al. included 366 patients, of which 187 patients had ulnar nerve in situ decompression and 179 patients had ulnar nerve anterior transposition. The total incidence of ulnar neuropathy was 19.3%, 23.5% in the anterior transposed group, 15.3% in the in-situ group. In 2017, Varecka and Myeroff reported 7.2% new postoperative ulnar nerve changes in a pooled analysis of the distal humeral fracture that included 222 patients. Vazquez et al. explained that neuropathy might bethe result of several causes, including trauma at the time of the injury, manipulation during splinting, intraoperative manipulation, entrapment in scar tissue, or hardware irritation. We performed bi-columnar fixation under brachial plexus anesthesia in the supine position in all 16 patients, including 5 patients with chronic disease with difficulty in general anesthesia. Our approach eliminated the manipulation of the ulnar nerve during surgery by placing the metal plate anterior to the ulnar nerve whilst preserving the soft tissue liner between them, thus minimizing nerve stimulation. In our retrospective analysis of our small cohort, we found no incidence of ulnar nerve symptoms.
This study evaluates the clinical and radiologic outcomes after a minimum follow-up of 12 months after bi-columnar anatomic locking plate fixation of LTFs in 16 elderly patients. We performed the surgery through a combined medial and lateral approach at the elbow without violating the elbow extension mechanism and without ulnar nerve dissection. The mean age at the time of surgery was 81 years (range, 65–91 years) and patients with poor general health received the surgery in the supine position with brachial plexus anesthesia. In most cases, it was possible to achieve adequate fracture fixation, and our results showed a mean range of motion of 10.9° of extension to 126.9º of flexion.
Xie et al. used combined medial and lateral approaches to treat 19 cases of type C (4 cases of C1, 12 of C2, and 3 of C3) fractures of the distal humerus. They were followed up for an average of 15.8 months and the mean age of the patients was 44 years (range, 18–79 years). They reported 2 minor and 1 major complication, but no postoperative ulnar nerve changes as in our results. We believe that for non-comminuted fractures of the distal articular surface of the humerus, this approach can be a reasonable option. However, for C3 type intercondylar fractures or comminuted articular surface fractures, it is relatively difficult to reduce and fix the articular fragments under direct vision through this approach, and it cannot be converted to olecranon osteotomy to expand the scope of exposure. Therefore, we suggest that this approach should be chosen carefully for C3 fractures.
The main shortcomings of our study are the small sample size and the short follow-up period. These limitations may be due to the low incidence rate of these fractures, and because most patients are in their old age. Our strengths are to exclude any other fracture pattern and to have included only a LTF pattern. Additionally, a single surgeon performed all the surgeries, reducing variability.
LTFs of the distal humerus in the elderly can yield satisfactory results with bi-columnar internal fixation through a combined medial and lateral approach.